INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21 through March 23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 23, 2011.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on review of administrative materials and an interview with the Chief Compliance Officer, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative material was reviewed on March 21, 2011 through March 22, 2011.
The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2009 through 2010 fiscal year ended on June 30, 2010. However, the facility's financial audit for this period was not completed until March 8, 2011.
An interview with the Chief Compliance Officer conducted on March 22, 2011 confirmed that the facility's financial audit for the facility's 2009 through 2010 fiscal year was not completed until March 8, 2011.
This is a repeat citation. The facility was cited on April 3, 2009 and on April 8, 2008 for a financial audit.
The facility's Plan of Correction for the April 3, 2009 citation was as follows:
"The audited financial statement for fiscal year ending 6/30/08 was completed and documented on 12/01/08.
An Addendum was submitted to DAPL inadvertently.
The CFO will ensure that a copy of the audited financial statement is forwarded to each site and available upon request. The Regional Director will ensure that a copy of the audit is available at the time of inspection. "
The facility's Plan of Correction for the April 8, 2008 citation was as follows:
"Holcomb Behavioral Health System's annual fiscal audit is done at the behest of Chimes,Inc.,our parent company. The Program Director will contact the audit firm and explain the necessity of completing the audit by the end of the calendar year."
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Plan of Correction
The Holcomb Behavioral Health Systems will arrange an independent financial audit of our Substance Abuse programs by the end of the close of the fiscal year. The Program Director will be responsible for compliance. Holcomb will arrange for this audit on an annual basis so that the problem does not reoccur. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and an interview with the Clinical Supervisor and Chief Compliance Officer, the facility documented consent to release information forms that allowed for the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5 (b), in three of five client records reviewed.
The findings include:
On March 23, 2011, five records were reviewed for consent to release information forms. The facility documented consent to release information forms that allowed for the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5(b) in client records # 3, 4, and 5.
Client record # 3
1. One consent to release information to a government agency dated 1/19/11 was completed allowing the release of the treatment/aftercare plan and discharge summary.
2. One consent to release information to a government agency dated 1/25/11 was completed allowing the release of the treatment/aftercare plan and treatment summary.
Client record # 4
1. One consent to release information to a government agency dated 1/25/11 was completed allowing the release of the treatment/aftercare plan summary and treatment summary.
Client record # 5
1. One consent to release information to a government agency dated 1/7/11 was completed allowing the release of the treatment/aftercare plan and assessment/evaluation summary.
2. One consent to release information to a government agency dated 1/7/11 was completed allowing the release of the treatment/aftercare plan and assessment/evaluation summary.
On March 23, 2011 a discussion was held with the Facility Director. During the discussion, the Facility Director reviewed the findings in client records # 3, 4, and 5.
This is a repeat citation. The facility was cited on April 8, 2008 on release of client information that exceeded which is permitted under 4 Pa. Code subsections 255.5.
The facility ' s Plan of Correction for the April 8, 2008 citation was as follows:
" Intake staff and clinicians will be educated by Coordinator in the protocol of the Informed and Voluntary consents, and will be presented with the specific Pa. Code 255.5 for future use. Supervisors/Coordinators will address this issue in weekly supervision and weekly chart reviews. "
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Plan of Correction
Holcomb's Chief Compliance Officer created a specific Release of Information form for all entities related to PA 255.5. This Release of Information, by its very structure limits the information that can be authorized for release by the client so that no information can be authorized for release beyond 255.5(b). The new form was disseminated to project staff the week of April 18, 2011. All hard copies of the old form were shredded. The new form will ensure clients do not consent to have information released beyond the information allowed in PA 255.5. All clients who signed the old form will be given the new form to sign no later than May 15, 2011. All newly admitted clients as of April 19, 2011 are given the new ROI with the 255.5 limitations. The Clinical Supervisor will conduct weekly chart reviews through May 20, 2011 to verify that only the new form is being utilized. After all charts are in compliance, the Clinical Supervisor will conduct ongoing, random chart reviews to ensure current and future compliance in utilization of the Release of Information in accordance with 4 Pa. Code subsections 255.5(b.) If the Clinical Supervisor discovers any violations, immediate remediation will be provided to each staff member as appropriate. Staff will receive quarterly reminders in staff meetings and/or trainings of the purpose and implication of being in compliance with Pa. 255.5(b) |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of the facility's written procedures for staff and clients to follow in case of an emergency, and a discussion with Facility Director, the facility failed to provide written procedures for staff and clients to follow in case of an emergency for external disasters.
The findings include:
The written procedures for staff and clients to follow in case of an emergency was viewed on March 23, 2011. The policy in the manual addresses internal disasters. However, the manual only addresses external disasters in general terms and is somewhat vague in addressing external disasters.
On March 23, 2011 a discussion was held with the Facility Director. During the discussion, the Facility Director reviewed the findings for the written procedures for staff and clients to follow in case of an emergency.
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Plan of Correction
Holcomb's Chief Compliance Officer has revised the Project's procedures regarding to include instructions for staff members and clients to follow in the case of an external disaster emergency. The updated policy will be reviewed with all staff members at the mandatory All Staff meeting to be held by the Clinical Supervisor on 4/27/11. All staff members will be reminded of this updated policy during each disaster drill performed. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records and an interview with the Facility Director, the facility failed to prepare and document alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on March 23, 2011. The records were reviewed from the period covering September 2010 to March 2011. In all of those months the facility had documented the same exit routes, all available exits, for each month.
The Facility Director confirmed on March 23, 2011 that the facility had documented the same exit routes each month.
This is a repeat citation. The facility was cited on July 31, 2007 and July 23, 2003 on alternate exit routes to be used during fire drills.
The facility's response to the citation issued on July 31, 2007 was as follows:
"The Facility Director reviewed with the agency's Director of Facility Management the requirement that fire drills document use of alternate exit routes. Future fire drills will be conducted in rotating manner to include all possible exit routes. Documentation will be maintained of use of these alternate routes."
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Plan of Correction
The Clinical Supervisor will train all staff members at the All Staff meeting on 05/04/2011 regarding the need to prepare and document alternate exit routes to be used during fire drills. The Facility Director and Clinical Supervisor will review the Fire Drill logs monthly and ensure that the logs document that staff members and clients are directed to alternating exit routes. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based a review of client records and discussion with the Facility Director, the facility failed to document a psychosocial evaluation in accordance with the facility's policy and procedures in four of five client records reviewed.
The findings include:
On March 23, 2011, five client records were reviewed for psychosocial evaluations. The facility did not document a psychosocial evaluation in accordance with the facility's policy and procedures in client records # 2, 3, 4, and 5.
The facility's policy titled: "Biopsychosocial Assessment", states:
"A clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
The client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; obstacles that might effect treatment are documented as well.
The client's preferred coping and defense mechanisms, conclusions regarding the client's appearance, behavior, and reactions during the evaluation will be documented and used to determined course of treatment.
Client's strengths/assets, support systems and preferred coping mechanisms. Potential treatment barriers that may impact the course of treatment. Mental status assessment.
Conclusions and treatment recommendations, including preliminary treatment planning. Recommendations should include treatment modalities and frequency. "
Client # 2 was admitted December 30, 2010. The psychosocial evaluation was completed on December 30, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor's conclusion/impressions as indicated in the facility's policy and procedures.
Client # 3 was admitted January 19, 2011. The psychosocial evaluation was completed on January 19, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, attitude toward treatment, and counselor's conclusion/impressions as indicated in the facility's policy and procedures.
Client # 4 was admitted January 25, 2011. The psychosocial evaluation was completed on December 3, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor's conclusion/impressions as indicated in the facility's policy and procedures.
Client # 5 was admitted January 7, 2011. The psychosocial evaluation was completed on January 7, 2011, but it did not include an evaluation of the client's problems/needs, assets/strengths, coping mechanisms, attitude toward treatment, and counselor's conclusion/impressions as indicated in the facility's policy and procedures.
On March 23, 2011 a discussion was held with the Facility Director. During the discussion, the Facility Director reviewed the findings in client records # 2, 3, 4, and 5.
This is a repeat citation. The facility was cited on April 23, 2010; April 8, 2008; August 23, 2006 and July 20, 2004 on psychosocial evaluations.
The facility's Plan of Correction for the April 23, 2010 citation was as follows:
" All current staff have been trained and retrained in the completion and timeliness of
the Psychosocial Evaluation. All clinical staff will fill this form out upon admission at the first face to face contact. Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.91 (b)(6), as well as facility policies 28.11.1 A, 28.11.3, 28.11.3.1, 28.11.3.2, 28.11.3.3, 28.11.3.7, 28.11.3.8, 28.11.3.9, 28.11.3.10, and 28.11.4. There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed. "
The facility's Plan of Correction for the April 8, 2008 citation was as follows:
"The Director of Clinical Services provided training to staff to ensure that all future assessments include a clinical assessment of client's assets,strengths,support systems,and negative factors that may impede treatment. The Program Coordinator will review this issue in weekly supervision and is responsible for this action."
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Plan of Correction
The Clinical Supervisor will ensure all staff members are trained at the mandatory All Staff meeting on 4/27/11, regarding the need for the psychosocial evaluation to include: a) A clear description of the client's presenting and underlying problems; client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment.
b) The client's assets, strengths or other factors that can contribute to the resolution of identified problems; the potential or available client support systems; obstacles that might effect treatment are documented as well.
c) The client's preferred coping and defense mechanisms, conclusions regarding the client's appearance, behavior, and reactions during the evaluation will be documented and used to determined course of treatment.
d) Client's strengths/assets, support systems and preferred coping mechanisms. Potential treatment barriers that may impact the course of treatment. Mental status assessment.
and
e) Conclusions and treatment recommendations, including preliminary treatment planning. Recommendations should include treatment modalities.
By May 31, 2011, all active client charts containing psychosocial evaluations will be revised to include the above necessary components. All clients admitted in the fuure will receive an evaluation that includes the necessary components.
The Clinical Supervisor will conduct chart reviews for the next 30 days to verify the necessary information is included in the psychosocial evaluation. If all charts are not in compliance at the end of the 30 days the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance in the completion of the psychosocial evaluation
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and interview with the Facility Director, the facility failed to document an individual treatment and rehabilitation plan in accordance with the facility ' s policy and procedures in two of five records reviewed.
The findings include:
On March 23, 2011, five client records were reviewed for an individual treatment and rehabilitation plan. The facility did not document an individual treatment and rehabilitation plan in accordance with the facility ' s policy and procedures in client records # 1 and 5.
The facility's policy titled: "Comprehensive Treatment Plan," states:
"A comprehensive treatment plan will be developed within 30 days of the date of admission. "
Client # 1 was admitted December 30, 2010; however, the facility did not document the individual treatment and rehabilitation plan until February 16, 2011.
Client # 5 was admitted January 7, 2011; however, the facility did not document the individual treatment and rehabilitation plan until February 24, 2011.
An interview with the Facility Director on March 23, 2011 confirmed that the facility did not document an individual treatment and rehabilitation plan in accordance with the facility ' s policy and procedures in client records # 1 and 5.
This is a repeat citation. The facility was cited on April 23, 2010 for individual treatment and rehabilitation plan.
The facility's Plan of Correction for the April 23, 2010 citation was as follows:
" All current staff have been trained and retrained in the completion and timeliness of the Comprehensive Treatment Plans. All clinical staff will fill this form out within the first 30 days of client ' s admission to the program. Effective immediately the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.92 (a). There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed. "
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Plan of Correction
The Clinical Supervisor will ensure all staff members are trained at the mandatory All Staff meeting on 4/27/11, regarding the need for completion and timeliness of the Comprehensive Treatment Plan. All staff members will complete the Comprehensive Treatment Plan within the first 30 days of any client's admission to the program.
The Clinical Supervisor will conduct chart reviews for the next 30 days to ensure all Comprehensive Treatment Plans are being completed as required. If all charts are not in compliance at the end of the 30 days the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance in the completion of the Comprehensive Treatment Plan.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and interview with the Facility Director, the facility failed to indicate the client ' s progress in the treatment and rehabilitation plan update in one of one records reviewed.
The findings include:
On March 23, 2011, one client record was reviewed for a treatment and rehabilitation plan update. The facility failed to document a treatment and rehabilitation plan update that included an indication of the client ' s progress in client record # 1.
The facility's policy titled: "Treatment Plans," states:
"Treatment plans will be updated at minimum every 60 days. Treatment plan updates will include a review of the client ' s progress in relationship to the stated goals within the comprehensive treatment plan. "
Client # 1 was admitted December 30, 2010. The treatment and rehabilitation plan update was completed on March 22, 2011, but it did not include an indication of the client's progress.
An interview with the Facility Director on March 23, 2011 confirmed that client record # 1 did not include an indication of the client's progress.
This is a repeat citation. The facility was cited on April 23, 2010; April 3, 2009; July 31, 2007; August 23, 2006; and July 20, 2004 for treatment and rehabilitation plan updates.
The facility's Plan of Correction for the April 23, 2010 citation was as follows:
"All current staff have been trained and retrained in the completion and timeliness of the updating of Comprehensive Treatment Plans every 60 days. All clinical staff will update treatment plans at least every 60 days. Effective immediatley [sic] the Clinical Supervisor will conduct regular chart reviews for the next 3 months. If all charts are not in compliance the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.92 (b), as well as facility policies 28.15, 28.15.1, 28.15.2, 28.15.3, 28.15.3.1 There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed."
The facility's Plan of Correction for the April 3, 2009 citation was as follows:
"D&A chart Treatment Plans will be updated every 60 days, effective 4/24/09. Clinical Support Staff will remind respective clinicians of upcoming deadlines by notation on the Service Rendered Sheets at the time of the appointments. This will be an on-going process. The Outpatient Coordinator will review D&A charts and ensure compliance, effective immediately. The Outpatient Coordinator will review all D&A charts for a three-month period of time and, if they are found to be in compliance, will review charts randomly on a quarterly basis."
The facility ' s Plan of Correction for the July 31, 2007 citation was as follows:
" Agency policy regarding the review and updating of treatment plans was reviewed with the Clinical Supervisor and clinicians. The Clinical Supervisor will conduct spot-checks to ensure compliance with this standard. "
The facility ' s Plan of Correction for the August 23, 2006 citation was as follows:
" The agency has a policy that client progress must be documented on a Progress Review form at the time of developing new treatment plans. This procedure was reviewed in detail with the counselor in the project. The clinical supervisor will monitor compliance with completion of this documentation and will be discussed periodically within supervision. "
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Plan of Correction
All staff members will receive training at the mandatory All Staff meeting on 4/27/11 regarding the completion and timeliness of the Treatment and Rehabilitation Plan Updates, including the requirement that treatment plan updates must include an indication of the client's progress.
The Clinical Supervisor is responsible for ensuring that all staff complete Treatment Plan Updates within 60 days and that the updates include an indication of the client's progress.
The Clinical Supervisor will conduct weekly chart reviews for the next 30 days to ensure that all Treatment and Rehabilitation Plan Updates contain the required elements. If all charts are not in compliance at the end of the 30 days. the Clinical Supervisor will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance in the completion of the Treatment and Rehabilitation Plan Updates.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and an interview with the Facility Director and Facility Coordinator, the facility failed to document a case consultation in three of four records reviewed.
The findings include:
On March 23, 2011, four client records were reviewed for documentation of a case consultation. The facility did not document a case consultation in client records # 1, 2, and 3.
The facility ' s policy titled: "Case Consultation, " states:
"Case consultation must be provided for each client on no less than a bi-monthly frequency. "
Client # 1 was admitted December 30, 2010. Client # 1 ' s record did not include documentation of a case consultation as of March 23, 2011.
Client # 2 was admitted December 30, 2010. Client # 2 ' s record did not include documentation of a case consultation as of March 23, 2011.
Client # 3 was admitted January 19, 2011. Client # 3 ' s record did not include documentation of a case consultation as of March 23, 2011.
An interview with the Facility Director and Facility Coordinator on March 23, 2011 confirmed that the facility did not document a case consultation in client records # 1, 2, and 3.
This is a repeat citation. The facility was cited on April 23, 2010; April 3, 2009; and July 31, 2007 on case consultations.
The facility ' s Plan of Correction for the April 23, 2010 citation was as follows:
" All current staff as well as the Clinical Supervisor have been trained and retrained in the completion, frequency, and timeliness of completing Case Consultation notes. Effective immediately the Facility Director will conduct regular chart reviews for the next 3 months to ensure the Clinical Supervisor has completed all case consultation notes timely. If all charts are not in compliance the Facility Director will continue regular chart reviews until all charts are in compliance. After all charts are in compliance the Facility Director will conduct random chart reviews to ensure current and future compliance with Licensure Standard 709.93 (a) (8), as well as facility policies 28.17, 28.17.1, 28.17.2. There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed. "
The facility ' s Plan of Correction for the April 3, 2009 citation was as follows:
" The Outpatient Coordinator will supervise clinicians on a bi-monthly basis, review the respective D&A chart information and clinicians' input, write the necessary bi-monthly Consultations, and enter into the respective D&A charts, effective immediately. "
The facility ' s Plan of Correction for the July 31, 2007 citation was as follows:
" Agency policy regarding the frequency and content of case consultations was reviewed with the Clinical Supervisor. The Facility Director will conduct periodic reviews to ensure compliance with this standard. "
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Plan of Correction
All staff members will receive training at the mandatory All Staff meeting on 4/27/11 regarding the required completion of Case Consultation notes every 60 days for each client in the program. By 06/01/11 the Clinical Supervisor will ensure that case consultation notes are completed for all active clients who are missing case consultation notes in their charts.
The Facility Director will conduct weekly chart reviews for the next 30 days to ensure that the Clinical Supervisor is completing Case Consultation notes as required. If all charts are not in compliance at the end of the 30 days the Facility Director will continue regular chart reviews until all charts are in compliance. After all charts are in compliance, the Facility Director will conduct random chart reviews to ensure current and future compliance in the completion of Case Consultation notes and provide additional training and/or corrective action to the Clinical Supervisor as needed. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and interview with the Facility Director, the facility failed to document an aftercare plan that included a contact person in two of three client records reviewed.
Also, based on a review of client records and interview with the Facility Director, the facility failed to document an aftercare plan in one of three client records reviewed.
The findings include:
On March 23, 2011, three client records were reviewed for documentation of aftercare plans. The facility failed to document an aftercare plan that included a contact person in client records # 6 and 8. The facility did not document an aftercare plan in client record # 7.
The facility's policy titled: "Aftercare Plan", states:
"The counselor and client will develop an aftercare plan, at minimum, two weeks prior to the client's anticipated date of discharge from treatment.
The aftercare plan is the client's plan for the future and will include:
The client's future goals with time frame. A description of the services that can be provided by the project after discharge, if appropriate. The method and frequency of continuing contact to provide client support. Criteria for re-entry into the project along with phone number an method of re-starting treatment."
Client # 6 was admitted September 13, 2010 and was discharged March 15, 2011. The aftercare plan was completed on January 13, 2011, but did not include a contact person.
Client # 7 was admitted November 2, 2010 and was discharged March 7, 2011. Client # 7's record did not include documentation of an aftercare plan as of March 23, 2011.
Client # 8 was admitted October 14, 2010 and was discharged February 25, 2011. The aftercare plan was completed on December 7, 2010, but did not include a contact person.
On March 23, 2011 a discussion was held with the Facility Director. During the discussion, the Facility Director reviewed the findings in client records # 6 and 8. Also, on the same day an interview with the Facility Director confirmed that client record # 7 did not include documentation of an after care plan.
This is a repeat citation. The facility was cited on April 23, 2010 for aftercare plans.
The facility's Plan of Correction for the April 23, 2010 citation was as follows:
"All current staff have been trained and retrained in the completion and timeliness of Aftercare Plans. This will ensure current and future compliance with Licensure Standard 709.93 (a) (9). There is an additional mandatory staff training scheduled for July 26, 2010 where the Facility Director and Clinical Supervisor will meet with all clinical staff to ensure all Licensure Standards and Facility Policies are understood and carefully followed. All issues addressed in the survey's deficiencies will be monitored by the Clinical Supervisor and Facility Director through weekly supervision of staff and charts."
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Plan of Correction
All staff members will receive training at the mandatory All Staff meeting on 4/27/11 regarding the required completion of an Aftercare Plan for each client if applicable.
The Clinical Supervisor will conduct weekly chart reviews of all discharged charts for the next 30 days to ensure all Aftercare Plans are completed as required. If all charts are not in compliance at the end of the 30 days the Clinical Supervisor will continue regular chart reviews until all discharged charts are in compliance. After all discharged charts are in compliance, the Clinical Supervisor will conduct random chart reviews to ensure current and future compliance in the completion of the Aftercare Plan.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on review of client records and an interview with the Facility Director, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual) in three of three client records reviewed for clients that receive medical assistance.
The findings include:
On March 23, 2011, three records were reviewed for documentation of the facility ' s medical director signature on client treatment plans. The facility ' s medical director did not sign the treatment plans in client records # 1, 2, and 3. The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (ii) specifies that " sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic ' s supervisory physician shall review and update each patient ' s treatment plan. Each review and update shall be dated, documented and signed in the patient ' s record by the clinic ' s supervisory physician. "
Client # 1 was admitted December 30, 2010. The preliminary treatment and rehabilitation plan was completed December 30, 2010, the individual treatment and rehabilitation plan was completed February 16, 2011, and the treatment and rehabilitation plan update was completed March 22, 2011. Client # 1 ' s record did not have documentation of the facility's medical director signature on the treatment plans as of March 23, 2011.
Client # 2 was admitted December 30, 2010. The preliminary treatment and rehabilitation plan was completed December 30, 2010 and the individual treatment and rehabilitation plan was completed January 30, 2011. Client # 2's record did not include documentation of the facility medical director's signature on the treatment plans as of March 23, 2011.
Client # 3 was admitted January 19, 2011. The preliminary treatment and rehabilitation plan was completed January 19, 2011 and the individual treatment and rehabilitation plan was completed February 2, 2011. Client # 3 ' s record did include documentation of the facility medical director's signature on the treatment plans as of March 23, 2011.
An interview with the Facility Director on March 23, 2011 confirmed that client records # 1, 2, and 3 did include documentation of the facility medical director's signature on the treatment plans.
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Plan of Correction
The Facility Director has informed the Clinical Supervisor and the Supervising Physician of the requirement for all Treatment and Rehabilitation Plans and Treatment and Rehabilitation Plan Updates to be signed by the Supervising Physician in accordance with 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (ii.) The Clinical Supervisor will ensure that by 05/09/11 all current Treatment and Rehabilitation Plans and Treatment and Rehabilitation Plan Updates are signed by the Supervising Physician. A system has been implemented in which each new Treatment and Rehabilitation Plan and each Plan Update is reviewed and approved by the Supervising Physician within 5 calendar days of each plan's completion as denoted by the date signed by the client. Additionally, all Treament and Rehabiliation Plans and subsequent updates will be reviewed, approved and signed by the supervising physician within the overall designated time frames as established by 55 Pa Code. The Clinical Supervisor will conduct ongoing chart reviews to ensure that treatment plans are being signed timely by the psychiatrist. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staffing requirements facility summary report, and an interview with the Human Resource Specialist and Chief Compliance Officer, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff in four of four records reviewed.
The findings include:
On March 22, 2011, four personnel records were reviewed to verify that staff had received the required training hours. The facility failed to document the required training hours in personnel records # 4, 5, 6, and 8.
Employee # 4, a counselor, was hired November 4, 2009, HIV/AIDS and STD/TB training was due November 4, 2010. However, personnel record # 4 did not include documentation of HIV/AIDS and STD/TB training as of March 22, 2011.
Employee # 5, a counselor, was hired November 2, 2009, HIV/AIDS and STD/TB training was due November 2, 2010. However, personnel record # 5 did not include documentation of HIV/AIDS and STD/TB training as of March 22, 2011.
Employee # 6, a counselor, was hired November 11, 2009, HIV/AIDS and STD/TB training was due November 11, 2010. However, personnel record # 6 did not include documentation of HIV/AIDS and STD/TB training as of March 22, 2011.
Employee # 7, the Medical Director, was hired in May 1995, HIV/AIDS training was due in May 1997. However, personnel record # 7 did not include documentation of HIV/AIDS training as of March 22, 2011.
An interview with the Human Resource Specialist conducted on March 22, 2011 confirmed that personnel records # 4, 5, and 6 did not include documentation of HIV/AIDS and STD/TB training. Also, an interview on the same day with the Human Resource Specialist and Chief Compliance Officer confirmed that personnel record # 7 did not include documentation of HIV/AIDS training.
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Plan of Correction
Employee #4 has recently submitted his TB/STD certificate. He completed that training on 6/8/09. He will complete the HIV/AIDS training on 7/12/11.
Employee #5 has recently submitted his HIV/AIDS and TB/STD training certificates. He completed HIV/AIDS on 9/10/09 and TB/STD on 10/9/08.
Employee #6 will complete HIV/AIDS on 7/12/11 and TB/STD training on 05/17/11.
Employee #7 will complete HIV/AIDS on 5/26/11.
Holcomb's Human Resources department will require that certificates for the above trainings not yet completed be provided by staff no later than 7 days following training completion. The HR Department and the Clinical Supervisor will collaborate in utilizing the agency's electronic personnel system as well as an excel preadsheet to track HIV/AIDS and TB/STD training due dates for all staff and verify completion of training by those dates. The Clinical Supervisor and Human Resources department have now instituated a tickler system to remind staff members to complete the HIV/AIDS and TB/STD trainings by the required dates. If any staff member fails to complete the mandatory HIV/AIDS and TB/STD trainings he/she will be removed from work duties until the trainings are completed.
The Chief Compliance Officer, in collaboration with the Clinical Supervisor, will be responsible for the compliance monitoring. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on review of personnel records, staffing requirements facility summary report, and interview with Human Resource Specialist and conversation with the Facility Director and Chief Compliance Officer, the facility failed to ensure that at least one-half of all training was provided by trainers not directly employed by the project in three of six records reviewed.
The findings include:
On March 23, 2011 the staffing requirements facility summary report was reviewed along with six personnel records for documentation that at least one-half of all training was provided by trainers not directly employed by the project during the facility's January 1, 2010 to December 31, 2010 training year. The staffing requirements facility summary report completed by the facility on March 17, 2011 indicated that more than one-half of training completed by employees # 4, 5, 6 was provided by trainers directly employed by the project.
The staffing requirements facility summary report indicated that employee # 4 received 17 hours provided by facility staff and 0 hours provided by outside trainer. However, a review of personnel record # 4 showed that employee # 4 received 13 hours provided by facility staff and 0 hours provided by outside trainer.
The staffing requirements facility summary report indicated that employee # 5 received 17 hours provided by facility staff and 4 hours provided by outside trainer. However, a review of personnel record # 5 showed that employee # 5 received 17 hours provided by facility staff and 0 hours provided by outside trainer.
The staffing requirements facility summary report and a review of personnel record # 6 indicated that employee # 6 received 17 hours provided by facility staff and 0 hours provided by outside trainer.
An interview with the Human Resource Specialist on March 22, 2011 confirmed that the hours reviewed in personnel records # 4, 5, and 6 are the correct training hours completed by employees # 4, 5, and 6 during the facility ' s January 1, 2010 to December 31, 2010 training year. Also, a discussion with Facility Director and Chief Compliance Officer on March 30, 2011 confirmed that more than one-half of training completed by employees # 4, 5, and 6 was provided by trainers directly employed by the project.
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Plan of Correction
The Clinical Supervisor will oversee that Employee #4, 5 and 6 resolve this deficiency and obtain additional training hours outside of the project. The Clinical Supervisor will be responsible for amelioration of the deficiences of these employees.
To ensure ongoing compliance with both new and existing employees, Holcomb's Human Resources department and the Clinical Supervisor will utilize the agency's electronic personnel system as well as an excel spreadsheet to track compliance with requirements for staff members to receive half of their training hours from trainers who are not employed by the facility. The Clinical Supervisor and Human Resources department have a tickler system in place to prompt staff members to accumulate training hours provided by trainers who are not employed by the project. If any staff member fails to comply with the requirements he/she will receive immediate corrective action and/or disciplinary action. The Director of Human Resources will be responsible for ongoing compliace. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on review of personnel records, staffing requirements facility summary report, and interview with the Human Resource Specialist, the facility failed to ensure that each counselor completed 25 clock hours of required training in four of four personnel records reviewed.
The findings include:
On March 22, 2011, four personnel records were reviewed for documentation of the required 25 hours of training. The facility failed to document 25 clock hours of training in personnel records # 4, 5, 6, and 7.
Employee # 4, a counselor, was hired November 4, 2009. The facility's training year is from January through December. The training year for January 1, 2010 to December 31, 2010 was reviewed. Personnel record # 4 only had documentation of 13 clock hours of training for the January 1, 2010 to December 31, 2010 training year.
Employee # 5, a counselor, was hired November 2, 2009. The facility's training year is from January through December. The training year for January 1, 2010 to December 31, 2010 was reviewed. Personnel record # 5 only had documentation of 17 clock hours of training for the January 1, 2010 to December 31, 2010 training year.
Employee # 6, a counselor, was hired November 11, 2009. The facility's training year is from January through December. The training year for January 1, 2010 to December 31, 2010 was reviewed. Personnel record # 6 only had documentation of 13 clock hours of training for the January 1, 2010 to December 31, 2010 training year.
An interview with the Human Resource Specialist on March 22, 2011 confirmed that the facility failed to document 25 clock hours of training in personnel records # 4, 5, and 6 for the January 1, 2010 to December 31, 2010 training year.
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Plan of Correction
Holcomb's Human Resources department and the Clinical Supervisor will utilize the agency's electronic personnel system as well as an excel spreadsheet to track the required 25 hours of trainings, mandatory completion dates, and actual completion dates for each Counselor in the program. The Clinical Supervisor and Human Resources department have a tickler system in place to remind Counselors to complete the necessary 25 hours of trainings by the required dates. If any Counselor fails to complete the required 25 hours of annual trainings he/she will be removed from work duties until all necessary trainings are completed.
The Chief Compliance Officer, in collaboration with the Clinical Supervisor, will be responsible for amelioration of this deficiency and ongoing monitoring of compliance. |